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Schedule Your Stay with Us

Scheduling a stay at Mary’s Place begins with completing the following Guest Questionnaire. Please complete all information required, and press the submit button at the bottom of the page. You will be contacted within 72 hours; in the event that you are not contacted within 72 hours, please contact our office to confirm that we have received your questionnaire. Every effort will be made to accommodate your requests.

Overnight Visits

Overnight Guests may check-in on Tuesdays or Fridays for a two-night stay.

Overnight Guests may check-in on Tuesday, Wednesday, Friday or Saturday for a one-night stay.

Check-in/check-out time is 11AM.

Day Visits

Day Guests may visit Tuesday-Saturday.

Check-in time may vary.

Mary’s Place By The Sea is operated by volunteers. Our services are provided free of charge by licensed practitioners. Please note: A letter from your doctor indicating you are under their care is needed. If you are requesting an oncology massage, please check with your doctor to make sure it does not interfere with your treatment. A doctor's note stating you are cleared to receive an oncology massage is needed prior to arrival. Please notify us of cancellation within 48 hours of your date of arrival.

Are you a New or Returning Guest?*

New Guest Returning Guest (Please note that we require a doctor's note for oncology massage and reflexology for returning guests, every six months.) Survivor (3+ years post-treatment)

Salutation*

First Name*

Last Name*

Address Line 1*

Address Line 2

City*

Select Your County*

If outside of New Jersey (Other), what County?

State*

Country*

If outside of USA, please list country:

Zip Code*

Home Phone*

Cell Phone

Email Address*

How long would you like to visit?*

Requested Check In Date*

Requested Check Out Date*

Check-in and Check-out is at 11am.

Please note: You will be personally contacted within 72 hours to confirm your reservation. If you have not received a call, please contact us at 732-455-5344.

Type of cancer*

Date of diagnosis (Date Format must be MM/DD/YYYY)*

Are you currently in treatment?*

If no, date of last treatment:

Where are you being treated?*

Age*

Birthday (Date Format must be MM/DD/YYYY)*

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact Email Address*

Emergency Contact Relation*

Are you currently on pain medication?*

Yes No

If Yes, please list medication(s)

Please indicate "Additional Medical Information" below: If you have any other medical or health condition we should be made aware of in an effort to protect all of our guests, volunteers and staff members. If none, simply state "none". This information will be kept confidential.

Additional Medical Information*

Please select 2-3 of the following INDIVIDUAL services that you MAY BE interested in receiving during your stay. (We do our best to accommodate your desired services based on the availability of our practitioners).

PLEASE SELECT THE FOLLOWING GROUP SERVICES THAT YOU MAY BE INTERESTED IN RECEIVING DURING YOUR STAY. (WE DO OUR BEST TO ACCOMMODATE YOUR DESIRED SERVICES BASED ON THE AVAILABILITY OF OUR PRACTITIONERS).

Group Services*

Gentle Yoga Expressive Writing Meditation Nutrition Education Prayer

You only need to indicate your Prayer Tradition if you are requesting prayer. Thank you.

Prayer Tradition (please indicate)

Would you like to receive individual counseling during your stay?*

Special Requests

How Did You Hear About Us*

Do you have any dietary restrictions or food allergies?*

Please list any dietary restrictions or food allergies.

TERMS AND CONDITIONS

1. I understand that Mary’s Place by the Sea is a non-smoking facility.*

Yes No

2. I understand that Mary’s Place has zero tolerance for firearms, illegal drugs and alcohol.*

Yes No

3. To maintain the peace and tranquility of the home, I agree to return to the house by 10PM.*

Yes No I am not staying overnight.

4. I agree not to share any medication with anyone at Mary’s Place by the Sea.*

Yes No

5. I understand that Mary’s Place by the Sea is not responsible for lost or stolen items.*

Yes No

6. I understand that if I do not provide a Doctor's note, I cannot receive an oncology massage.*

Yes No

7. I understand that all services are COMPLIMENTARY, and that every effort will be made to provide my desired services based on the availability of practitioners.*

Yes No

8. I understand that Mary's Place by the Sea reserves the right to call 911 in the event of an emergency and at the discretion of the staff and volunteers.*

Yes No

Photo and Video Disclaimer: From time to time, we capture photos and/or videos of our guests and visitors to be used on social media sites including our social media pages and other printed materials such as our brochure. We respect your privacy and request your permission to take an occasional photo of you during your stay at Mary's Place by the Sea. Please indicate your permission by selecting "yes" or "no".

Photographs and Videos*

Digital Signature*

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Our Mission

Our mission is to support women with cancer through integrative services which complement their medical treatment and empower, educate and support their healing: mind, body and soul.

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